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f <br />DEC-09--2008 TUE 04;50 PM <br />FAX NO. 3037727039 <br />P. 08 <br />RECEIVED <br />NOTICE OF INTENT TO CONSTRUCT MONITORING HOLE(S) <br />Please type or print legibly in black or blue ink DEC 10 <br />STATE EN6MEER <br />Colorado Division of Water Resources 1313 Sherman St Room 821 Denver CO 80203 w.,'"°"°R`E' <br />COLO <br />i-none <br />Contact J <br />Company Tetra Tech <br />Address 1900 South. Sunset Street <br />Suite IF <br />City, State, Zip Lommont. CO 80501 <br />Phone 503-772-5282 Fax No. 3037,772-7039 . <br />Driller Lic. No. (if applicable) <br />Name Lafarge North America <br />Address 10170 Church Ranch Way. Suite 200 <br />Westminster. CO 80021 <br />Well Owner's Phones 303-657.4000 <br />Location: Na '/., S9,'/.-, Section AL <br />Township §&N / S. Range GO VV E / W, PM <br />County Weld <br />Subdivision <br />Lot . Blk. Fig. <br />SlteMroperty Address 5011 F Street <br />Greeley, CO 80631 <br />Hole(s) to be constructed: Number t-.- <br />Estimated depth M Ft. Aquifer <br />Purpose of Mon"itoring Hole(s) Groundwater <br />monftorlnq <br />Approximate Date of Construction 12-15.2008 <br />(Mutt be at least 3 days prior to Co wvucdon) <br />Landowner's Name: Tim Iverson Jeremy Deuto <br />Authorized Signature <br />ACKNOWLEDGEMENT FROM STATE ENGINEER'S OFFICE <br />FOR OFFICE USE ONLY <br />MH- 048268 PROCESSED BY zdwc= <br />Div. I WD ? BAS MD <br />DATE ACKNOWLED= 1?2 <br />CONDITIONS OF MONITORING HOLE ACKNOWLEDGEMENT <br />A COPY OF THE WRITTEN NOTICE OR ACKNOWLEDGEMENT SHALL BE AVAILABLE AT THE DRILLING SITL <br />Notice was provided to the State Engineer at least 3 days prior to construction of monitoring & observation hole(s). Constriction <br />of the hole(s) must be completed with 90 days of the date notice was given to the Stabs Engineer. Testing and/or pumping shall not <br />exceed a total of 200 hours unless prior written approval Is obtained from the State Engineer. Water diverted during testing aball nQ? be <br />used for beneflclal purposes. The owner of the hole(s) Is responsible for obtaining permit(s) and complying with all rules and regulations <br />pertaining to the discharge of fluids produced during testing. <br />All work must comply with the Wabr Weil Construction Rules, 2 CCR 402-2. Minimum construction standards must bo met or a <br />variance obtained. Standard permit application and work report forms are found on the DWR website at htt Ab ww.wat%state.co.us. <br />Well Construction and Test Reports (GW3411) must be completed for each hole drilled. The licensed contractor or authorized Individual <br />must submit the completed forms to this office within e0 days of drilling. <br />Unless a well permitts obtained, the hole(s) must be plugged and sealed within one (1) year after construction. <br />An Abandonment Report (form GWS-E) must be submitted for each hole plugged with 00 days of plugging & seating. The <br />monitoring hole acknowledgement number, owner's structure name, and hole owner's name and address must be provided on all well <br />permit application(s), well construction and abandonment reports. <br />The owner of the hole(s) should maintain records of water quality testing and submit this data to the State Engineer upon reque$L <br />A monitoring hole cannot be converted to a production water well, except for purposes of remediation (recovery) or as a permanent <br />Dvm teritrg system, it constructed In ac wrdance with the Water Well Construction Rules and policies of the State Engineer. <br />THIS ACKNOWLEDGEMENT OF NOTICE DOES NOT INDICATE THAT WELL PERMIT(S) CAN BE APPROVED. <br />IF HOLES WILL NOT BE CONSTRUCTED UNDER THIS NOTICE WITHIN 90 DAYS, PLEASE WRITE- 'NO HOLES CONSTRUCTED' <br />ON A COPY OF THE AND FAX THE COPY TO THE DIVISION OF WATER <br />RESOURCES. '2 ,,, /l. ?./